Claim for Death Benefits

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form OJP FORM 3650/5 CLAIM FOR DEATH BENEFITS	Form and Instruction	Modified	Available
1121-0024_PSOB DEATH JUSTIFICATION 2006.doc	Supporting Statement A	Uploaded 2007-05-18	Available
PSOB LEGISLATION.pdf	Supplementary Document	Uploaded 2006-11-03	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
12363	CLAIM FOR DEATH BENEFITS	Form and Instruction	Modified

ICR Details

OMB Control No: 1121-0024	ICR Reference No: 200611-1121-004
Status: Historical Inactive	Previous ICR Reference No: 200404-1121-001
Agency/Subagency: DOJ/OJP	Agency Tracking No:
Title: Claim for Death Benefits
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn and continue	Conclusion Date: 07/30/2007
	Date Received in OIRA: 05/21/2007
Terms of Clearance: Needs to be resubmitted for emergency extension for 6 months. Expiration is 7/31/07.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2007	36 Months From Approved	01/31/2008
Responses	320	0	320
Time Burden (Hours)	480	0	480
Cost Burden (Dollars)	3,000	0	3,000

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Abstract: The Public Safety Officers Death Benefits (PSOB) Program provides a one-time benefit of $295,194.00 to the eligible survivors of local, state and federal public safety officers whose deaths result from traumatic injuries substained in the line of duty. The agency requires the information requested on this form to identify survivors and determine their eligibility for the Public Safety Officer Death Benefit in accordance with the statutory requirements found in 42 USC Sec. 3796. Respondents include surviving spouses, children and/or parents of deceased public safety officers.

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Authorizing Statute(s): US Code: 42 USC 3796 Name of Law: Public Safety Officers Benefits
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 9587	03/02/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 25783	05/07/2007
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
CLAIM FOR DEATH BENEFITS	OJP FORM 3650/5	CLAIM FOR DEATH BENEFITS

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Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Increase documentation is required for the one time payment. Decrease in applicants is normal. A major increase in the number of applicants in the prior years were due to the terrorist attack on Sept 11, 2001. Many public safety officers were killed in the line of duty.

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Annual Cost to Federal Government: $42,413

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 05/21/2007

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